Why the "Doughnut Hole" Metaphor is Inside Out

The recent passage of health care legislation in the U.S. Congress has got linguist Neal Whitman ruminating over a reform-related metaphor that doesn't make much sense when you stop to think about it.

With President Obama's signing of the health care reform bill, we move a step closer to finding out whether it will solve the problems it is intended to solve: the out-of-control increases in insurance premiums, the maddening denial or dropping of coverage due to preexisting conditions, the tasty-sounding "doughnut hole" of Medicare prescription drug coverage.

For those who have gotten lost in the talk of public options, death spirals, and Cadillac policies during the past year of debate on health care reform, the doughnut hole is a metaphor for a coverage gap in Part D of Medicare — the part established in 2006 to cover prescription drugs. The basic idea is that prescription drug costs up to some dollar amount X are at least partially covered by Medicare. (There's a deductible you have to meet, and after that the coverage is 75%.) Above X, coverage stops, but it kicks back in at some larger dollar amount Y. The values of X and Y have varied between 2006 and now; currently, they stand at $2830 and $4550. In his Political Dictionary, William Safire credited Rep. Willie Tauzin (R-La) with creating the metaphor in 2001, and a union known as the Alliance for Retired Americans with popularizing it in 2002.

The doughnut-hole metaphor has us picture the dollar amounts as corresponding to areas of concentric circles, as shown in Figure 1 (not to scale):

Viewed this way, the gap in coverage does indeed look like a doughnut.

But reading about the doughnut hole in the newspaper or hearing about it on the radio, I kept having a feeling I wasn't understanding something. It was when I called upon my real-world knowledge of doughnut structure that I finally realized it wasn't the issue itself that was troubling me, but the choice of metaphor. Figure 2 shows a typical donut. We can observe that it is a glazed, cake doughnut, without sprinkles. We can also see that the gap in coverage from Figure 1 corresponds not to the doughnut hole, but to the sweet, cakey goodness of the doughnut itself.

In other words, when we're talking about Medicare prescription drug coverage, doughnut hole doesn't mean "hole in a doughnut" the way housework means "work in the house." That's the ordinary meaning of doughnut hole. With that meaning, doughnut hole is what linguists call a determinative compound, in which one noun has something or other to do with the other one. In this case, the noun doughnut restricts the meaning of the noun hole to just those holes that are located in doughnuts. But in Medicare jargon, doughnut hole means "hole that is (metaphorically) a doughnut," the way houseboat means "boat that is a house." Linguists call this kind of compound a descriptive compound, in which one noun tells what the other one is, or at least what the other one is like. In this case, the noun doughnut says that we're talking about holes that are (like) doughnuts.

In employing the doughnut metaphor, we're trying to use two ideas associated with doughnuts: the idea of a ring, and the idea of a hole. The trouble is that those two ideas are manifested in fundamentally different parts of a doughnut.

A better metaphor for the gap in prescription drug coverage would be a castle moat. First of all, it's both a ring and a hole: a ring-shaped, water-filled ditch separating two areas of dry land. Second, the area of dry land inside the moat — the castle — is an area of safety, corresponding to the covered prescription-drug costs. Third, moats are often associated with danger — if not from crocodiles or poisonous snakes, then from arrows raining down from the castle. This corresponds well with the fear-inducing, in-between area of prescription-drug costs not covered by Medicare. Beyond the moat is more dry land, corresponding to the resumed prescription-drug coverage. The metaphor starts to break down here, since the land outside the moat is not safe like the land inside it. It might be overrun with invading armies deploying catapults or other siege weapons. Even so, this metaphor doesn't suffer from the topological confusion of the doughnut-hole metaphor.

The doughnut actually is a pretty good metaphor for one aspect of modern health care, just not Medicare prescription drug coverage. It could stand for your own medical insurance policy. The doughnut hole is the annual deductible for your plan — the uncovered costs that fall below a certain minimum. The doughnut itself is the medical expenses that your insurance company covers once you've met your deductible. And beyond the doughnut lie the medical expenses incurred after you've reached your annual coverage limit.

Of course, transferring the doughnut metaphor to a different health care-related situation would just create confusion, so we're stuck with it as it is. However, when the doughnut hole is filled, don't think of Medicare Part D as now being like a jelly doughnut, with no hole. What's being filled is a doughnut-shaped hole, so a metaphor for the resulting situation would be something like one of those small, spherical doughnuts that are playfully called doughnut holes, surrounded by a traditional, toroidal doughnut, surrounded by ... some more doughnut material that just forms a flat sheet, I guess. At that point, with neither a ring nor a hole having any significance, I think the doughnut-hole metaphor will be done.

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Neal Whitman blogs at Literal-Minded, where he writes about linguistics in everyday life from the point of view of a husband and father. He taught English as a second language while earning his degree at Ohio State University; has published articles in Language, Journal of Linguistics, and other publications; and writes occasional scripts for the podcast "Grammar Girl's Quick and Dirty Tips for Better Writing."
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Comments from our users:

Thank you, Mr. Whitman, for a thorough and interesting explanation of this widely-used metaphor. I tried to explain this metaphor to several colleagues at a coffee break a few years back - I wasn't successful. Where were you when I needed professional help? I’m not sure the metaphor deserves this effort, but many readers will thank you.

Adding to the confusion is the further use of "doughnut hole" in many doughnut shops--for a round ball the size of a the hole in the doughnut. (I'm not sure but would presume that in the past these were actually made from dough cut away in shaping a doughnut; I think now they are made separately.) In any case, it means that a "doughnut hole" can designate either an absence or a presence ...

I live in Canada so am not affected by and do not have the sort of coverage described.

So I've very grateful for this explanation as I've been following the health care debate avidly. (born in the USA)

Under the Prescription Drug coverage in my province, the metaphone doesn't apply as the coverage has earnings eligibility requirements. So if I consider our supplemental plans, I have coverage amounting to a small hole. The actual sweet stuff from tax money doesn't apply until I've spent far more than we get in prescriptions.

Thanks for taking the time to address this so called metaphor. Every time I heard it I had to pause as it visually did not make any sense. It is a shame the people at Krispy Kreme or Dunkin Doughnuts did not take the time to clarify this. It would have been a great PR bonanza for them and they would have raked in the dough.

i am very sorry, because I didn't know the word. As I am not greedy, I never buy that kind of cake.

Nevertheless when I look at your picture I understand your explanation concerning the "doughnut hole", I imagine concentric circles , and the differents parts between them. Exept here you have two circles.

Do you find something in the hole? For the professional help you have!!!.

In mathematic you have the centre of your circles in any case. According where you were to , you want , you claim a heath covered. , apartially covered. The more you are near the centre of the "doughout" the more your covered is insignificant.

Huh. The metaphor always made sense to me, but I see the visual differently in my head. The doughnut described here sees the rise in expenses as some kind of expansion in two dimensions (hence the reference to a "flat sheet" in the last paragraph).

But I always envisioned the continuum of coverage as a *linear* trip across the diameter of a doughnut. From $0 (the outer edge of the doughnut) to $2,830 (the edge of the hole), you're covered -- and there's pastry there, so the metaphor holds. From $2,830 to $4,550, you're traversing the doughnut's hole (no pastry, not covered).

At $4,550, then, you reach the other side of the hole and hit "pay doughnut" again, and you're good until you reach the opposite outer edge, which is whatever big number you need (even infinity, I guess).

Granted, such a doughnut wouldn't be symmetrical, but that's how the fried pastry shaped itself in my head when I first encountered the metaphor.

Any chance maybe that's how Congressman Tauzin saw it, too? Can any other readers back me up here?

The whole system is falling apart!
As a medical doctor I understood some of the explanations of Medigap and other coverages that fail miserably to return coverage for payment in good faith.
As to dental insurance with my coverage at the "top" tier level, the annual coverage (only for "covered" care) maxes out at $1500.00! My current costs are running up to $50,000.00 due to implantation surgical restoration on my self alone!
I don't blame those who go "bare" and feel they have achieved a more, and more clever scheme to avoid the need to understand the doughnut hole!

Green's donut explanation makes sense to me, if not to the system which is being rent asunder. We don't have dental coverage under our medicare in Canada unless it's accidental (and hospital) or pulling multiple teeth under anesthetic. Supplemental covers some, but about what the doctor says. Maybe a bit more here.

@GreenCaret:
You might be right! I'm more comfortable with a linear visualization, too, but never managed to integrate it with the doughnut metaphor with the idea of a straight line across the doughnut. I'd be interested in hearing how other people have visualized this doughnut.

As a recent retiree I was not familiar with the subject acronym, and I put it on a list of items to investigate. Now I can really cross that one off the list. Can I also rely on you to analyze the difference between a Tea Party member, a Redneck, and a Tea Bagger? How exactly does a Death Spiral work (sounds like a bad thing)and how does it tie in to the new health reform bill?

Mark, I think the difference in those expressions might depend on which news outlet you watch, or the political orientation of your paper.

If you watch Fox News, a Tea Party member is usually simply a person fed up with the incumbents, taxation, crowding the states with programs they can't afford, and generally, being Big Brotherish with the decision making -- all from Washington.

The other two terms are more derogatory, and perhaps, since you are so near to the center of the universe, Washington, DC, more commonly used.

I think with those we'd have to be careful of the politics on this site. Usually we haven't swung one way or the other too much with our comments.

GreenCaret gets an A, for either understanding better than anyone else what was intended; or for making sense out of a confusing metaphor that was never explained. An alert donut maker could still profit using his explanation. Neal Whitman did a nice technical article and only added a little to the overall confusion. Rana